Cancer in low- and middle-income countries: what should - - PowerPoint PPT Presentation

Cancer in low- and middle-income countries: what should we do?

Franco Cavalli

MD, FRCP Scientific Director Oncology Institute

• f Southern Switzerland

CH-6500 Bellinzona

1 2 3 4 5 6 7 8 TB AIDS Malaria All 3 Cancer

Millions of victims

Cancer kills more globally!

WHO (2003)

5 10 15 20 25 30 35

Deaths Cases

Millions

World Estimated Cancer Burden in 2030

2000 2030 (Population growth) 2030 (+1% annual increase of the risk) 2030 Annual percent change in Incidence (+1.3) and Mortality (-0.4) in France (1978-2000)

Remontet et al., 2002

1970 15% of global burden 2008 56% of global burden 2030

• ca. 70% of global burden

Cancer in developing countries

! 2008 = 12.7 Mio. new cancer cases ! attributable fraction for infectious agents: 16.1% (2 Mio. cases) less developed countries 22.9% more developed countries 7.4% Variation: New Zealand 3.3% ! sub-Saharian Africa 32.7%

H.Pylori, hepatitis B/C and HPV

account 1.9 Mio. cases (95%)

Global burden of cancers attributable to infections in 2008: a review and synthetic analysis (IARC)

• C. de Martel et al. Lancet Oncology 2012; 13:607-615

Cancer mortality (fatality ratio)

75% low income countries 72% middle income countries 64% upper-middle income countries 46% high income countries

• P. Farmer et al. Lancet 2010; 376:1186-93

Breast cancer

(thousands)

Cervical Cancer

(thousands) 1980 2010 1980 2010 cases 641 1600 378 460 deaths 425 (50-50%)* 220 (80-20%)* deaths < 49 yrs in developing countries 68 (70-30%)* 60 (85-15%)* ( )* = proportion developing / developed countries

incidence: 1980-2010 BC 3.1% / year " CC 0.6% / year "

MH Forouzanfar et al. Lancet 2011; 378:1461-84

Breast and cervical cancer in 187 countries between 1980 and 2010: a systematic analysis

Breast cancer survival (5-year) Cervical cancer survival (5 year) Life expectancy GNI per head (2009 US$) Health expenditure per head (2009 US$) Low income The Gambia Uganda India Lower-middle income Philippines China Thailand Upper-middle income Costa Rica Turkey High income South Korea Singapore 12% 46% 52% 47% 82% 63% 70% 77% 79% 76% 22% 13% 46% 37% 67% 61% 53% 63% 79% 66% 57 52 65 74 75 72 81 74 83 83 330 370 990 1460 2490 3240 5530 8090 21210 34640 22 28 40 63 108 136 488 465 1362 1148 Health-care and economic data for ten countries by World Bank country income classification levels and 5-year survival for breast and cervical cancer.

• B. Anderson et al., Lancet Oncology 2011; 12:387-98

Survival of children with cancer in economically developed countries and in low-income countries

Access to Radiotherapy

IAEA$has$ini*ated$PACT$to$ comprehensively$address$this$urgent$ problem,$and$is$moving$its$ radiotherapy$programmes$to$a$public$ health$model.$$

Cancer Drugs versus Cancer

60% 61% 18% 16% 5% 18% 17% 5%

The 5/80 Cancer Disequilibrium

About 5% of global resources spent in low and middle income countries which account for almost 80% of the disability-adjusted life-years lost worldwide to cancer.

Sloanza, Gelband H eds. Cancer control opportunities in low- and middle-income countries. Washington D.C.: Institute of Medicine of the National Academies, National Academies Press; 2007

The looming disaster in developing countries

Sum of ! mainly poverty-related tumors (cervical,

• esophagus, liver)

! tumors linked to western style of life (breast, lung, prostate, colorectal) ! lack of primary and secondary prevention ! lack of resources for treatment

• F. Cavalli. Nature Clinical Practice Oncology 2006; 11:582

Figure

• R. Ribeiro et al. Lancet Oncology 2008; 9-721-729

Correlation between government health expenditure and pediatric cancer survival

Annual&government&spending&on&health&care&per&capita&($US)&

Structure and efficiency of health care system KEY for the fight against cancer

“Universal health coverage is fundamental to improving the lives of people”

Peter Anyang Nyong Kenia’s Health Minister

Lancet 2012; 379:494

Current evolution (I)

Anglophone sub-Saharian African Countries have seen 30 years of undermining of their health systems by structural adjustement and successive fiscal crises, contributing to wholesale emigration

• f trained health workers.

Current evolution (II)

Many Asian and Latin-American health systems are tiered and fragmented because of the unregulated growth of private health care and successive externally-driven initiatives.

Current evolution (III)

Public health systems in the countries of the former Soviet Union, previously universally accessible -albeit often inefficient- have been disrupted by reductions in funding and rapid privatization.

Health systems strengthening: current and future activities.

• J. Sundvall et al. Lancet 377:1222-24; 2011

Current evolution (IV)

Explosion of cost of systemic treatment, even for

• ld drugs (e.g. Thalidomide, Thiotepa, etc.)

(US prize is determinant) Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) has “exacerbated the problem with no gain for developing countries

• R. Smith. Lancet 2009; 373:684-91

What to do? (I)

! Prevention! (Tobacco " Africa) Enforce FCTC ! Early detection adapted to local situation e.g. BGHI

Cancer in developing countries: can the revolution begin? Lancet Oncology 2011; 12:201

What to do? (II)

Palliative: Curative: ! twinning ! essential drugs (WHO) ! UNIQUE ! vertical programs (???) ! change of rules!

1086: La Mascota Project

150-200 USD/year Long-term twinning global-program ! training and supervision of helath professionals ! building inpatients - outpatients structures and laboratories facilities ! use of protocols tailored to the local possibilities ! clinical research ! use of part of resources for social help (Lost to therapy #)

Lancet 1998; 352:1923-26

Expansion of cancer care and control in countries

• f low and middle income: a call to action

3 examples: ! international partnership ! inclusion in national incurance programs ! expansion through a national center of excellence

• P. Farmer et al. Lancet 2010; 376:1186-93

UN SUMMIT on NCDs (19-20 September 2011)

Additionally, the Declaration clearly acknowledges cancer as a unique disease in many respects, with specific commitments to prevention and early

• detection. We welcome commitments to:

! Give greater priority to early detection, screening and diagnosis of NCDs including cancer screening programs (particularly breast and cervical cancer) ! Increase access to Hepatitis B and HPV vaccines as part of national immunization programs to prevent infection-related cancers.

UN SUMMIT on NCDs (19-20 September 2011)

However, there remain some areas where commitments fall short of expectations. The Declaration lacks specific targets including no

• verall goal of reducing preventable deaths. More

work is now needed to convince governments around the world to commit to reduce the avoidable deaths from NCDs by 25% by 2025 - a target WHO believes to be achievable. In addition, there are no commitments to increase the proportion of development assistance devoted to health

• utcomes.

New WHO Resolutions

• 1. To reduce NCD-mortality in people <70 yrs

by 25% till 2025

• 2. To prepair second Framework Convention

(first FMCT) devoted to RD, mainly related to low income countries.

! 0.01% of BIP to be devoted.

Geneva, May 25th, 2012

Changes of rules

! abandon principle of patents ! compensate industry for discovery ! most of research ( F I ! III) to be financed by public resources.

• J. Stieglitz. blog “Project Syndicate”

Next steps

27-28 October 2012, Lugano, Switzerland:

World Oncologic Forum (WOF)

(Are we winning the war on cancer?)

Thank you